Friday, March 17, 2006

The "backward" chest X-ray in Scrubs

An astute future doc on the SDN forums noticed recently that the opening sequence of Scrubs (a sitcom which I confess I haven't seen yet) features an incorrectly oriented chest X-ray. In accordance with the universal standard for viewing X-ray images (or "plain films" as radiologists seem to prefer these days), you're supposed to imagine viewing a patient that is facing you, so the left side of the film is the patient's right side. The Scrubs title shot (see below) clearly shows a heart pointing the wrong way (i.e., to the right instead of left). Also, the diaphragm bulges higher on the wrong side (left instead of right). Flip the image and everything looks normal.

It turns out that the gaffe was intentional:

The chest X-ray in the title sequence was hung backwards during the first season, then corrected briefly for season 2, but then returned to being backwards. Bill Lawrence states that having the X-ray backwards was intentional as it signified that the new interns were inexperienced. This error was parodied in "My Cabbage" (original airdate: February 28, 2006), with Cabbage (an Intern), attempting to read a chest X-ray backwards.

Sounds reasonable. But there is another, much less likely but much more anatomically interesting possibility. Perhaps the patient in the chest film has situs inversus. In this rare (1 in 10,000) congenital condition, an individual's internal organs appear to be the mirror image of the normal arrangement. The liver is on the left instead of the right, the spleen is on the right instead of the left, the left lung has 3 lobes instead of 2, etc. There is also some evidence that brain anatomy in situs inversus is inverted too.

For me, the most curious thing about situs inversus is that people with it usually have a normal life expectancy. Apparently in most people it's just an uncommon but normal variation, kind of like red hair or left-handedness. Indeed, the only real risk of situs inversus is confusing a clinician! For example, appendicitis normally causes pain in the right lower quadrant of the abdomen. In patients with situs inversus...you guessed it, left lower quadrant. There's always something to keep doctors on their toes.

P.S. For more information, check out this blog entry on situs inversus. It has a link to a nice New York Times article, and many comments by readers with situs inversus.

I really enjoy the blog, I'm a veterinary student, and I enjoy your posts on anatomy. Especially since I am fortunate enough to have to know the anatomy of at least eight of the major species this semester.

Some people with Situs Inversus have something called Kartagener's syndrome which is also associated with immotile cilia and thus frequent respiratory infections. They are also sterile.

I noticed the screw up on the first episode and just figured it was on purpose. The film might also represent solitary dextrocardia not associated with situs inversus. In that case, the apex of the heart points to the right and everything else is normal.

One detail supporting the situs inversus hypothesis: the id tag on chest-r-xays is usually placed so as to indicate the patient's right side. The apex of the heart thus points to the right on the above radiograph.

Anonymous #1: I know there are many doctors who regret going into medicine. Will I become one of them? I truly hope not, but if I do, I imagine it wouldn't be too hard to get back into teaching (as soon as I've paid off the loans). Medicine is an extraordinary career, but it's no panacea. Like every job (including teaching), it has its pros and cons. I'm reminded of a quote by the writer James Baldwin: "The price one pays for pursuing any profession or calling is an intimate knowledge of its ugly side."

My wife worked at the local rehab hospital in Cincinnati and a few years ago a tramatic brain injury patient had Situs Inversus. This may have been an opportunity to discover if part of the brain was also inverted. I don't think it was investigated. .... sigh...

MY NAME IS ROBERT Z. I WAS RESPONSIBLE FOR THE XRAY IN THE OPENING SEQUENCE OF SCRUBS. I HAD GIVEN THE PRODUCTION COMPANY A SKULL, ABDOMEN,PELVIS AND TWO CHEST XRAYS WITH THE SCRUBS TITLE. ONE OF THE CHEST PICS WAS REVERSED AND I HAD PUT A BIG X ACROSS IT WITH A RED GREASE PENCIL. SOMEONE ERASED THE X AND THEY DECIDED TO USE THAT IMAGE. BY THE WAY THEY USED TO READ CHEST XRAYS IN THAT PROJECTION ABOUT40 YEARS AGO. I HAVE BEEN IN MEDICAL IMAGING SINCE THE EARLY 1970s. I ALSO SUPPLIED IMAGES TO "ER" ALL THE "CSIs","GREYs ANATOMY" "HOUSE MD" AND ABOUT 30 MORE POLICE AND MEDICAL SHOWS OVER THE LAST 14 YEARS.

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About Me

Freshly minted MD (2010), specializing in radiology. In my former life I taught gross anatomy and neuroanatomy. After a few years of teaching, I finally came to my senses and decided to pursue my childhood dream of becoming a doctor. The adventure continues!